An Unusual Cause of Acute Upper Gastrointestinal Bleeding: Acute Esophageal Necrosis

Abstract

Acute esophageal necrosis (AEN), also called “black esophagus,” is a condition characterized by circumferential necrosis of the esophagus with universal distal involvement and variable proximal extension with clear demarcation at the gastroesophageal junction. It is an unusual cause of upper gastrointestinal bleeding and is recognized with distinct and striking mucosal findings on endoscopy. The patients are usually older and are critically ill with shared comorbidities, which include atherosclerotic cardiovascular disease, diabetes mellitus, hypertension, chronic renal insufficiency, and malnutrition. Alcoholism and substance abuse could be seen in younger patients. Patients usually have systemic hypotension along with upper abdominal pain in the background of clinical presentation of hematemesis and melena. The endoscopic findings confirm the diagnosis and biopsy is not always necessary unless clinically indicated in atypical presentations. Herein we present two cases with distinct clinical presentation and discuss the endoscopic findings along with a review of the published literature on the management of AEN.

Acute Esophageal Necrosis: A Rare Case of Upper Gastrointestinal Bleeding from Diabetic Ketoacidosis

“…Up to 36% of patients will succumb to their underlying critical illness; however, AEN specific mortality is approximately 6%. 2 , 3 , 5 The typical patient is an elderly male (mean age 68; male to female ratio 4:1) that presents with signs and symptoms of upper gastrointestinal bleeding (65-90% of cases) but AEN can be an incidental finding during endoscopy. 5-7 Though the exact etiology is unclear, it is likely multifactorial consisting largely of tissue hypoperfusion/mucosal ischemia, decreased mucosal buffering, and gastric content reflux that acutely exceeds the protective and regenerative properties of vulnerable esophageal mucosa enabling significant ischemic/chemical injury of the esophagus.…”

“… 2 Due to the paucity of data on this condition, a medical therapy gold standard has not been established but treatment usually focuses on the causative condition. 3 , 4 We present a case of a 56-year-old male presenting with diabetic ketoacidosis, shock, and coffee ground emesis that was found to have AEN. Considering the rarity of this condition, future clinical trials will likely not be possible.…”

Comprehensive review of acute oesophageal necrosis

“…Of these cases, we managed to extract data from 79 articles having 105 cases of AON (online supplementary table 1). 5–82 Data could not be extracted from (n=13) of the articles containing a total of (n=20) cases 4 83–95. The most common reasons for these were unavailability of complete data or the language being other than English.…”

Black esophagus as an autopsy discovery: a challenging interpretation

“…Case reports published in literature reviews were also included on the condition that patient history was sufficiently detailed. The endoscopy series initially included 88 publications, of which 26 publications on a total of 41 deceased patients were retained (Gurvits et al 2015;Ben Soussan et al 2002;Averbukh et al 2018;Barnes et al 2014;Day and Sayegh 2010;Del Hierro 2011;Essamri et al 2001;Grudell et al 2006;Julian Gomez et al 2008;Kalva et al 2016;Katsinelos et al 2004;Koop et al 2016;Lahbabi et al 2013;Maher and Nassar 2008;Odelowo et al 2002;Ramos et al 2008;Rodrigues et al 2016;Roman Fernandez et al 2014;Salem et al 2015;Shafa et al 2016;Shah et al 2017;Sharma et al 2016;Singh et al 2011;Wu and Wu 2014;Monteiro et al 2019;Khan et al 2019). The autopsy series initially comprised 13 publications, of which 11 publications on a total of 17 patients were retained in this review.…”